Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness - 2009
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RECEIVED BY
FIRST REPORT OF INJURY OR ILLNESS
SENT TO DIVISION DATE
DIVISION RECEIVED DATE
CLAIMS-HANDLING ENTITY
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call 1-800-342-1741
or contact your local EAO Office
Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
NAME (First, Middle, Last)
Social Security Number
Date of Accident (Month-Day-Year)
Time of Accident
AM
PM
HOME ADDRESS
EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)
Street/Apt #: _________________________________________________________
City: _________________________ State: _______________ Zip: ______________
TELEPHONE
Area Code
Number
OCCUPATION
INJURY/ILLNESS THAT OCCURRED
PART OF BODY AFFECTED
DATE OF BIRTH
SEX
_________ / _________ / _________
M
F
EMPLOYER INFORMATION
FEDERAL I.D. NUMBER (FEIN)
DATE FIRST REPORTED (Month/Day/Year)
COMPANY NAME: ___________________________________________________
D. B. A.: ____________________________________________________________
NATURE OF BUSINESS
POLICY/MEMBER NUMBER
Street: _____________________________________________________________
City: _________________________ State: _______________ Zip: ______________
TELEPHONE
Area Code
Number
DATE EMPLOYED
PAID FOR DATE OF INJURY
_________ / _________ / _________
YES
NO
LAST DATE EMPLOYEE WORKED
WILL YOU CONTINUE TO PAY WAGES INSTEAD OF
EMPLOYER'S LOCATION ADDRESS (If different)
WORKERS' COMP?
YES
_________ / _________ / _________
Street: _____________________________________________________________
LAST DAY WAGES WILL BE PAID INSTEAD OF
RETURNED TO WORK
YES
NO
City: ________________________ State: _______________ Zip: ______________
WORKERS' COMP
IF YES, GIVE DATE
LOCATION # (If applicable) ____________________________________________
_________ / _________ / _________
_________ / _________ / _________
DATE OF DEATH (If applicable)
RATE OF PAY
HR
WK
PLACE OF ACCIDENT (Street, City, State, Zip)
_________ / _________ / _________
$ _________________ PER
DAY
MO
Street: _____________________________________________________________
AGREE WITH DESCRIPTION OF ACCIDENT?
Number of hours per day
City: _________________________ State: _______________ Zip: ______________
______________________
YES
NO
Number of hours per week
______________________
COUNTY OF ACCIDENT ______________________________________________
Number of days per week
______________________
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a
NAME, ADDRESS AND TELEPHONE
statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),
OF PHYSICIAN OR HOSPITAL
F.S.
I have reviewed, understand and acknowledge the above statement.
__________________________________________________________________
_______________________________________________
EMPLOYEE SIGNATURE (If available to sign)
DATE
__________________________________________________________________
_______________________________________________
EMPLOYER SIGNATURE
DATE
AUTHORIZED BY EMPLOYER
YES
NO
CLAIMS-HANDLING ENTITY INFORMATION
1(a) Denied Case - DWC-12, Notice of Denial Attached
2. Medical Only which became Lost Time Case (Complete all required information in #3)
TH
1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached
Employee’s 8
Day of Disability
_________ / _________ / _________
TH
Entity’s Knowledge of 8
Day of Disability _________ /_________ / _________
3. Lost Time Case - 1st day of disability _________ / _________ / _________
Full Salary in lieu of comp?
YES
Full Salary End Date ________/ ________ / ________
Date First Payment Mailed _________ / _________ / _________
AWW ____________________________
Comp Rate ____________________________
T.T.
T.T. - 80%
T.P.
I.B.
P.T.
DEATH
SETTLEMENT ONLY
st
st
Penalty Amount Paid in 1
Payment $___________
Interest Amount Paid in 1
Payment $__________
REMARKS:
INSURER NAME
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
INSURER CODE #
EMPLOYEE'S CLASS CODE
EMPLOYER'S NAICS CODE
SERVICE CO/TPA CODE #
CLAIMS-HANDLING ENTITY FILE #
Form DFS-F2-DWC-1 (03/2009) Rule 69L-3.025, F.A.C.
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